Honor veterans ... and the VA

The Department of Veterans Affairs shows how American health care ought to work

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Today, in parades and ceremonies across the country, Americans will celebrate Veterans Day. The holiday is a time to commemorate the heroism and service of our bravest men and women. But with the high-stakes political struggle over health-care reform nearing a climax, we also should spend this Veterans Day honoring -- and learning from -- another source of pride for our country: Veterans Affairs medical centers. VA medical centers serve as an example of the kind of integrated and coordinated health-care delivery that we should expect to see in our reformed system.

Today, most Americans get their health care through a hodgepodge of providers, networks, testing facilities and insurance companies. The delivery of health care is divided into individual silos, each one isolated from the next. Electronic medical records, which could help link the silos together, either aren't used or don't communicate with each other.

This fragmentation of care makes it hard for providers to keep track of a patient's medical big picture, leaving the burden of connecting the dots to the patient. It's part of the reason why one in five Medicare patients admitted to the hospital is rehospitalized within 30 days and why health care is cheaper in Minneapolis than it is in Miami.

The VA stands in contrast to this bleak picture of American health care. For one, it's the truest model of integrated care: Under one roof (or a referral away) is not just a hospital but a multispecialty medical center, complete with an array of outpatient clinics, social work and psychological services, and radiology and labs.

Say your primary-care doctor wants you to see a dermatologist for a skin lesion. Instead of what most of us go through now -- a referral into a different system, processing the insurance paperwork again, waiting to find out test results from an independent lab -- you see the specialist down the hall and the results and recommendations are fed right back to your primary-care doctor.

The way care is delivered in the integrated system is better: Several studies have shown that the VA outperforms other health-care systems across a number of measures of the quality of outpatient care -- and in consumer satisfaction.

The success of the VA system also comes from its primary-care-based approach to coordinating patient care.

At the VA where I practice, each veteran is assigned to a primary-care team and to a specific primary provider. The primary-care team is the hub of care; extending out like spokes are the specialists and other skilled providers who deliver additional care.

At the VA, coordinating care between the hub and the spokes is facilitated because all providers not only share the same building but also the same laboratory, pharmacy and -- the glue that holds it all together -- a comprehensive electronic medical record. This setup allows the primary care team to better manage their patients' care by connecting the dots for them--and keeping tabs on their medical big picture.

A few options have been proposed to help the rest of the U.S. health system deliver integrated and coordinated care like the VA does.

The medical-home model, which is advocated by several physician groups, makes primary-care teams explicitly responsible for care coordination (and compensates them for this task).

In another model, so-called accountable-care organizations provide the full spectrum of clinical care, all within the same system, so as to avoid fragmentation and duplication. Providers in these organizations share accountability (and potentially payment) for patient care, which puts the emphasis on the quality of care from start to finish, not just on individual services. As a result, health care can be better -- and cheaper.

The Geisinger Health System in Pennsylvania and the Group Health Cooperative in Seattle are well-established examples of accountable-care organizations that have helped inform efforts to broaden the reach of this type of health-care delivery model.

Republican or Democrat, for the "public option" or against it, everyone in this country deserves health care that is delivered with a team approach, that encompasses a full set of integrated services, that emphasizes shared accountability for patients' overall health and that utilizes tools to facilitate care coordination.

Health-care delivery in a reformed system should look more like the VA. On this Veterans Day, let's honor those who have served -- and their health- care system.


Dr. Matthew Press , a native of Pittsburgh, is a practicing internist and Robert Wood Johnson Foundation clinical scholar at the University of Pennsylvania and the Philadelphia VA Medical Center ( www.med.upenn.edu/rwjcsp ).


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